Meaningful Use news update

Senators question HITECH, meaningful use ahead of hearing
Jennifer Bresnick, April 17, 2013

It’s HHS Secretary Kathleen Sebelius’ turn in the hot seat today as she faces a Congressional hearing over the 2014 budget for the Department of Health and Human Services, and a group of senators are already expressing “significant concerns” over the implementation of the HITECH act and its associated meaningful use of health information technology.  In a public letter released yesterday, six Republican senators question whether the $35 billion over ten years allotted to the HITECH act is being well-spent, asserting that there is a “lack of data to support the Administration’s assertions that this taxpayer investment is being appropriately spent and actually achieving the goal of interoperable health IT.”...

Dear Madam Secretary,

We write to request information about the department's progress promoting federal health information technology adoption and standards. The American Recovery and Reinvestment Act OF 2009 included the Health Information Technology and Economic and Clinical Health (HITECH) Act, which aimed to promote the adoption and meaningful use of health information technology (health IT). Since the passage of the HlTECH Act in 2009, the Department of Health and Human Services (HHS) has released hundreds of pages of regulations to implement the program. In addition, $35 billion over ten years will be spent to implement this program.

The HITECH Act was enacted to promote the adoption and meaningful use of health IT. The goal of the program is to create a secure network in which hospitals and providers can share patient data nationwide. Unfortunately, we have significant concerns with the implementation of the HITECH Act to date, including the lack of data to support the Administration's assertions that this taxpayer investment is being appropriately spent and actually achieving the goal of interoperable health IT.

Congress has an obligation to conduct oversight of government programs to ensure the effective use of taxpayer dollars. In keeping with that role, today we released "REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT" (enclosed). This white paper outlines concerns with current health IT policy, including interoperability, increased costs, potential waste and abuse, patient privacy, and sustainability.

We respectfully ask that in conjunction with the Offic eof the National Coordinator of Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS),you provide a detailed written plan to address the concerns in the enclosed white paper, to ensure that health IT taxpayer investments today are sound and result in a safe, secure, interoperable health IT system in the future. Specifically, please address your plans to achieve interoperabi1ity, control billing costs, prevent waste and abuse, protect patient privacy, and ensure the program is sustainable.

We also ask that, in conjunction with ONC and CMS, you respond in writing to the following questions: 

1. Please provide a list of every contract or task order awarded to perform work related to the HITECH Act. Please include the recipient, the amount and length of the contract, and the nature of the work to be performed.
2. ONC planned to contract with Mathematica Policy Research to build a model to understand the linkages between all of the different health IT programs, as well as the cost and quality implications of health IT. Please provide an update on the status of this global evaluation and provide copies of any findings reported to HHS, ONC, or CMS to date.
3. ONC contracted with the National Opinion Research Center at the University of Chicago (NORC) to conduct an evaluation of state health IT programs as mandated in HITECH. Please provide an update on the status of this evaluation and provide copies of any findings reported to HHS, ONC, or CMS to date.
4. ONC funded $250,000,000 in cooperative agreements to Beacon Communities that, according to ONC,"have already made inroads in the development of secure, private, and accurate systems of EHR adoption and health information exchange."How many of these communities will have to reduce their standards in Stages 2 and 3 to avoid penalty payments? What work has HHS, ONC, or CMS done to evaluate the progress of each of the Beacon Community awardees and how they will be impacted by Stage 2 and 3 milestones?
5. The American Institute for Research (AIR) was awarded a contract to evaluate the effectiveness of different HIT activities. The evaluation was to include a survey of providers and regional extension centers (RECs) and capture information such as how the RECs affected EHR adoption in the region. Please provide an update on the status of this contract and provide copies of any findings reported to HHS, ONC, or CMS to date. Has any additional work been done to ensure the sustainable of RECs? 
6. ONC was planning to conduct evaluations of HITECH implementation in three cycles with separate deliverable dates to the National Coordinator on February 1, 2012; April 1, 2012; and September I, 2012. ONC was also expected to produce an overall summary of all three reports. Please provide copies of all reports delivered by ONC to the National Coordinator. If some of these reports have not been completed, please provide an explanation and the expected date of completion.
7. Section 232 of the HITECH Act required the National Coordinator to assess and publish the impact of health IT in communities with health disparities and in areas with a high proportion of individuals who are uninsured, underinsured, and medically underserved (including urban and rural areas), identify practices to increase the adoption of health IT by health care providers in such communities, and assess the use of health IT to reduce and better manage chronic diseases. Please provide an update on the status of this assessment and provide copies of any related findings reported to ONC to date.

We hope this process will begin a robust dialogue. It is our goal to work cooperatively together to learn more about the issues raised here and to address the problems identified. We request this response in writing by June 16, 2013.

Sincerely,

"Has any additional work been done to ensure the sustainable of RECs?"

The long answer is "no," not by ONC, anyway. In fact, "Blame the RECs" time may well be drawing nigh.
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FROM THE "WHITE PAPER" (pdf)

...In addition to our concerns about interoperability, costs, oversight, and security, we have an even more basic concern that the $35 billion effort will be wasted if providers are not able to comply with requirements or maintain the health IT system over the long-term. HITECH was included in a controversial, rushed legislative environment and enacted in the midst of an already complicated and increasingly burdensome regulatory landscape. Multiple overlapping reporting and regulatory burdens will make it difficult for providers to stay abreast of developments and direct the majority of their time to patient care.

The pressure on providers will only further increase when incentive payments turn into penalties. At that point, it will be even more challenging for many providers to maintain health IT systems, which will need to be constantly monitored, managed, and upgraded to keep up with changing technologies.

These long-term risks are even more pronounced for solo practitioners and other small- to medium-size offices that do not have the benefit of achieving economies of scale and spreading their acquisition and maintenance costs over a larger pool of patients. For example, one study of ongoing EHR costs for small and solo practices estimated that the ongoing costs to maintain an EHR system averaged over $8,000 per provider per year. Providers are already facing large payment changes and administrative costs due to changes in federal policy and regulations.

Incentives for Compliance to Be Replaced by Penalties for Noncompliance

As the EHR incentive program continues to progress, long-term uncertainty for physicians is still a problem that needs to be addressed as physicians fear the looming penalties. In 2015, physicians and hospitals will begin incurring penalties in the form of decreased Medicare reimbursement for not meeting meaningful use requirements. While it is true EHR adoption has been increasing nationwide, research suggests that most physicians who have already applied for incentive payments or intend to apply for them are not gaining meaningful use under CMS’s regulatory standards. This means that initial estimates overestimated providers in compliance, leaving many more providers out of compliance than originally thought.

To avoid a penalty, those who participated in the EHR incentive program in 2011 and 2012 must demonstrate meaningful use for a full year in 2013, the final year of Stage 1 of meaningful use, to avoid the penalty beginning January 2015. Furthermore, these providers must then continue to show meaningful use of EHRs every subsequent year in order to avoid future penalties.

According to the Government Accountability Office, participation for 2011, the most recent year data is available from an entity outside of the U.S. Department of Health and Human Services, shows that participation in the program is low. As noted in the table below, less than 40 percent of hospitals are participating in the Medicaid program and less than 20 percent participate in the Medicare program. Even with an increase in participation before 2015, one could project a scenario where more than a third of all hospitals are penalized...

I find it interesting that neither the acronym "REC" nor the words "regional" or "extension" appear one time in this "white paper." Here's as close as you get:

ARRA appropriated $2 billion in the HITECH Act for grants to fund health IT infrastructure and grants to states for low-interest health IT loans.  The Agency for Healthcare Research and Quality (AHRQ) has awarded $300 million in federal grant money to over 200 projects in 48 states topromote access to and encourage adoption of health IT. Over $150 million in Medicaid Transformation Grants have been awarded to 35 states and territories for health IT initiatives in the Medicaid program, pursuant to the Deficit Reduction Act of 2005.

...A number of entities were created by Congress and the administration to address health IT implementation issues.  The Office of National Coordinator for Health IT (ONC) established the Health Information Security and Privacy Collaboration (HISPC) to develop a national privacy and security framework.  The Healthcare Information Technology Standards Panel (HITSP), another ONC creation, is a public-private effort to develop standards for the certification of health IT products.  The Department of Health and Human Services secretary created the National eHealth Collaborative (NeHC), a public-private advisory body to make recommendations on health IT adoption and usability.  The AHRQ created the online National Resource Center for Health IT to serve as a public resource for information on health IT.  Finally, the Health Resources and Services Administration (HRSA) works to improve access and use of health IT for safety net providers.

RECs comprise about $665 million of that $2 billion, but we don't even make the radar here. We're just glommed into all of this summary recounting (though, we did make for a bit of "sustainability" hand-wringing in the Non-Non Partisan Sebelius Public Letter).

Maybe that's a good thing.

I will have more to say on this document once I've fully scrutinized it. Here's a nice little zinger for now, though:

 ...a “cash out the door” metric may be an overly important metric for senior officials at CMS. In the opening session of the 2012 Office of the National Coordinator for Health IT Annual Meeting, Farzad Moshashari [sic], National Coordinator for Health IT, highlighted how much money has been spent and suggested it was the measure of success of the EHR program. He recognized the CMS staff who have helped facilitate the “$9 billion” that has been provided to states that “had the highest proportion of eligible [providers] paid.” Additionally, during the meetings of the Health IT Policy Committee, the program metrics discussed are the number of providers participating in the meaningful use program and how much has been paid out in incentive payments. Those metrics fail to capture the true goal -- provider progress toward interoperability.

It is beyond dispute that ONC has been haranguing the RECs to get the MU registration Body Count and the Milestone 3 count up. I'm glad I don't have to listen to that self-serving crap anymore during weekly REC staff meetings.

AIRPORT UPDATE

I'm on my way to Honolulu today (18th). Going through the "White Paper" while waiting at LAS for my flight.

In 2009, the Health Information Technology and Economic and Clinical Health (HITECH) Act was passed as part of the American Recovery and Reinvestment Act (ARRA).5 The HITECH Act was enacted on the heels of several existing federal incentive programs designed to promote the adoption and effective use of electronic health records (EHRs). The ultimate goal of this act was to create standards for the secure exchange of patient data nationwide, whether the site of care was a hospital or a local primary care physician’s office. In other words, the goal of the HITECH Act was for providers across the country to be able to adopt technology that would allow them to store and access EHRs, to share them seamlessly in a timely manner, and to create a network for providers’ systems to be interoperable. ARRA appropriated approximately $35 billion for the Office of National Coordinator for Health IT and the Centers for Medicare and Medicaid Services (CMS) to achieve this goal. Now, nearly four years after the enactment of the HITECH Act, and after hundreds of pages of regulations implementing the program, we see evidence that the program is at risk of not achieving its goals and that $35 billion in taxpayer money is being spent ineffectively in the process.

Yeah, but the program has only been operational for three years, not four. Moreover -- irritatingly -- RECs spent a year or more "recruiting" EPs and EHs, when contractual engagement of RECs should have been made a condition of eligibility; you want in? Sign up with your REC. 

And, it must be noted that the path to the ultimate goal (accurate, secure, point-of-care PHI liquidity) is more realistically a ten year one. Not that I don't share some of the concerns; my panoptic views are by now a matter of voluminous public record here, proffered freely and studiously without any commercial intent or slant. I'm not a Health IT geek, I'm an analyst and an equal opportunity iconoclast.
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The "privacy" thing:

We are concerned the administration has not done enough to protect sensitive patient information in a cost-effective manner. Among other problems, regulations related to payments made to providers do not require providers to demonstrate that the technology is secure; consequently, patients’ sensitive, personal medical information may be at risk.

Well, the regulations regarding the security of ePHI as set forth in Meaningful Use criterion Core 15 are both comprehensive and onerous (taken seriously), spanning the gamut of 45 CFR 164.3nn, as I have written about in some detail. Widespread compliance with Core 15 is another matter. We'll see how the HHS OCR and Figliozzi audits shake out in that regard. Concerns about ePHI protection were publicly aired two years ago (see my prior post linked in this paragraph).
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More to come...